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Lisa M. Najavits, PhD / 2014 PTSD

a) What is PTSD? DSM-IV definition: After a trauma (the experience, threat, or witnessing of physical harm, e.g.,c rape,

hurricane), the person has each of the following key symptoms for over a month, and they result in decreased ability to function (e.g., work, social life): intrusion (e.g., flashbacks, nightmares); avoidance (not wanting to talk about it or remember); arousal (e.g., insomnia, anger).

Simple PTSD results from a single event in adulthood (DSM-IV symptoms); Complex PTSD results from multiple traumas, typically in childhood (broad symptoms, including personality problems) b) About PTSD

Rates: 10% for women, 5% for men (lifetime, US). Up to 1/3 of people exposed to trauma develop PTSD. Men have higher rates of trauma, but women have more childhood trauma, and are more likely than men to develop PTSD if exposed to trauma.

Treatment: if untreated, PTSD can last for decades; if treated, people do recover. Most effective treatments: cognitive-behavioral (i.e., coping skills training) and exposure (tell the trauma story).

Substance Abuse a) What is substance abuse?

The compulsion to use despite negative consequences (e.g., legal, physical, social, psychological). Note that neither amount of use nor physical dependence define substance abuse.

DSM-IV term is substance use disorder, with substance abuse a milder form, and substance dependence more severe. b) About substance abuse

Rates: 35% for men; 18% for women (lifetime, US) It is treatable disorder and a no-fault disorder (i.e., not a moral weakness) Two ways to give it up: cold turkey (give up all substances forever; abstinence model) or warm turkey

(harm reduction, i.e., any reduction in use is positive step; moderation management, i.e., some people can use in a controlled fashion-- but only those not dependent on substances, and without co-occurring disorders)

The Link Between PTSD and Substance Abuse a) About PTSD and substance abuse

Rates: Of clients in substance abuse treatment, 12%-34% have current PTSD. For women, rates are 33%-59%.

Gender: For women, typically a history of sexual or physical childhood trauma; for men, combat or crime Drug choice: No one drug of choice, but PTSD associated with severe drugs (cocaine, opioids); self-

medication in 2/3 of cases (i.e., PTSD first, then substance abuse). b) Treatment issues

Other life problems are common: e.g., other Axis I disorders, personality disorders, interpersonal and medical problems, inpatient admissions, low compliance with aftercare, homelessness, domestic violence).

PTSD does not go away with abstinence from substances; and, PTSD symptoms are widely reported to become worse with initial abstinence.

Separate treatment systems (mental health versus substance abuse). Fragile treatment alliances and multiple crises are common. Treatments helpful for either disorder alone may be problematic if someone has both disorders (e.g., exposure, twelve-step groups, benzodiazepines). Also, some messages in substance abuse treatment may be problematic: hitting bottom, confrontation.

c) Recommended treatment strategies

Treat both disorders at the same time, according to experts. Also, clients prefer this. Decide how to treat PTSD in context of active substance abuse. Options:

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Type 1) Focus on present only (coping skills, psychoeducation, educate about symptoms) [safest approach, widely recommended]

Type 2) Focus on past only (tell the trauma story) [high risk; works for some clients] Type 3) Focus on both present and past

d) Diversity Issues In the US, rates of PTSD do not differ by race (Kessler et al., 1995). Substance abuse: Hispanics and African-Americans have lower rates than Caucasians; Native Americans have higher rates than Caucasians (Kessler et al., 1995, 2005). Rates of abuse increase with acculturation. Some cultures have protective factors (religion, kinship). It is important to respect cultural differences and tailor treatment to be sensitive to historical prejudice. Also, terms such as trauma, PTSD, and substance abuse may be interpreted differently based on culture.

The Seeking Safety Treatment a) About Seeking Safety A present-focused therapy to help clients (male and female) attain safety from PTSD and substance abuse. 25 topics that can be conducted in any order:

Interpersonal topics: Honesty, Asking for Help, Setting Boundaries in Relationships, Getting Others to Support Your Recovery, Healthy Relationships, Community Resources

Cognitive topics: PTSD: Taking Back Your Power, Compassion, When Substances Control You, Creating Meaning, Discovery, Integrating the Split Self, Recovery Thinking

Behavioral topics: Taking Good Care of Yourself, Commitment, Respecting Your Time, Coping with Triggers, Self-Nurturing, Red and Green Flags, Detaching from Emotional Pain (Grounding)

Other topics: Introduction/Case Management, Safety, Life Choices, Termination Designed for flexible use: can be conducted in group or individual format; for women, men, or mixed-gender; using all topics or fewer topics; in a variety of settings; and with a variety of providers. b) Key principles of Seeking Safety

Safety as the goal for first-stage treatment (later stages are mourning and reconnection) Integrated treatment (treat both disorders at the same time) A focus on ideals to counteract the loss of ideals in both PTSD and substance abuse Four content areas: cognitive, behavioral, interpersonal, case management Attention to therapist processes: balance praise and accountability; notice countertransference (sadism, scapegoating, victimization, giving up on clients); all-out effort; self-care

c) Additional features Trauma details not part of group therapy; in individual therapy, assess clients safety and monitor carefully (particularly if has history of severe trauma, or if client is actively using substances) Identify meanings of substance use in context of PTSD (e.g., substance use as revenge against abuser; reenactment of abuse toward self; to remember feelings or memories; to numb out feelings or memories; to live; to die) Optimistic: focus on strengths and future Help clients obtain more treatment and attend to daily life problems (housing, AIDS, jobs) Harm reduction model 12-step groups encouraged, not required Give clients control whenever possible Make the treatment engaging: quotations, everyday language Emphasize core concepts (e.g., You can get better)

d) Evidence Base Seeking Safety is established as an evidence-based model. Positive outcomes have been found in the 17 completed studies on Seeking Safety. For a description of each study and the full article, go to www.seekingsafety.org (section Outcomes). The studies include pilots, randomized controlled trials, controlled trials, multisite trials, and a dissemination study.

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e) Resources on Seeking Safety. All below are available from www.seekingsafety.org. Research articles: all articles related to Seeking Safety can be freely downloaded (section Outcomes). Training: training calendar and information on setting up a training (section Training). Consultation: on clinical implementation, research studies, evaluation projects (contact Lisa Najavits) Adherence Scale: can be freely downloaded (section Assessment). Assessment tools: can be freely downloaded (section Measures). The resources below can be ordered from the website, section Order: Book (English): Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002). Provides clinician guide and all client handouts. Translations (Spanish, French, German, Swedish, Dutch, Polish, Chinese) Video training series: four videos provide training on Seeking Safety. (1) Seeking Safety (two hour training video by Lisa Najavits); (2) Asking for Help (one-hour demonstration of a group session with real clients); (3) A Clients Story (26 minute unscripted life story by a male trauma survivor) and Teaching Grounding (16 minute example of the grounding script from Seeking Safety with a male client); (4) Adherence Session (one hour session that can be rated with the Seeking Safety Adherence Scale). Poster: poster of over 80 safe coping skills, 24x30, full-color, scenic background (in English or Spanish). Card deck: all of the safe coping skills and quotations on cards, with ideas for games.

Contact Information

Contact: Lisa Najavits, PhD, Treatment Innovations, 28 Westbourne Road, Newton Centre, MA 02478; 617-299-1620 [phone]; info@seekingsafety.org [email]; www.seekingsafety.org [web] Would you like to be added to the Seeking Safety website to list that you conduct Seeking Safety? If so, please email Lisa basic information. Example: Boston, MA: Karen Smith, LICSW; group and individual Seeking Safety; private practice with sliding scale. 617-300-1234. Karensmith@netzero.com.

Resources on Substance Abuse and PTSD

a) Substance abuse National Clearinghouse for Alcohol and Drug Information 800-729-6686; www.health.org National Drug Information, Treatment and Referral Hotline 800-662-HELP; http://csat.samsha.gov Alcoholics Anonymous 800-637-6237; www.aa.org SMART Recovery (alternative to AA) www.smartrecovery.org Addiction Technology Transfer Centers www.nattc.org Harm Reduction Coalition 212-213-6376; www.harmreduction.org b) Trauma / PTSD International Society for Traumatic Stress Studies 708-480-9028; www.istss.org International Society for the Study of Dissociation 847-480-9282; www.issd.org National Centers for PTSD (extensive literature on PTSD) 802-296-5132; www.ptsd.va.gov National Child Traumatic Stress Network 310-235-2633; www.nctsn.org National Center for Trauma-Informed Care 866-254-4819; mentalhealth.samhsa.gov/nctic National Resource Center on Domestic Violence 800-537-2238; www.nrcdv.org Department of Veterans Affairs 800-827-1000; www.va.gov EMDR International Association 866-451-5200; www.emdria.org Community screening for PTSD and other disorders www.mentalhealthscreening.org Sidran Foundation (trauma information, support) 410-825-8888; www.sidran.org

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Educational Materials

Books on PTSD 1. Herman J. L. (1992). Trauma and Recovery. New York, Basic Books. 2. Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the Therapist: Countertransference and Vicarious

Traumatization in Psychotherapy with Incest Survivors. New York: WW Norton. 3. Briere, J.N. & Scott, C. (2006). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment.

Thousand Oaks, CA: Sage. 5. Fallot, R.D. & Harris, M. (2001). Using Trauma Theory to Design Service Systems. San Francisco: Jossey-Bass. 5. Hoge, C. C. (2010). Once a Warrior--Always a Warrior: Navigating the Transition from Combat to Home--Including

Combat Stress, PTSD, and mTBI. GPP Life Press. Books on Substance Abuse 1. Beck A. T., Wright J., et al. (1993). Cognitive Therapy of Substance Abuse. New York: Guilford. 2. Marlatt G., Gordon J. (1985). Relapse Prevention. New York: Guilford. 3. Fletcher, A. (2001). Sober for Good. Boston: Houghton Mifflin. 4. Najavits L. M. (2002). A Womans Addiction Workbook. Oakland, CA: New Harbinger. 5. Miller, W. R., Zweben, A., et al. (1995). Motivational Enhancement Therapy Manual (Vol. 2). Rockville, MD: U.S.

Department of Health and Human Services. Obtain from www.health.org (free). Books on PTSD and Substance Abuse 1. Najavits L. M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York: Guilford. Spanish and other translations also available (www.seekingsafety.org) 2. Ouimette, P. & Brown, P. (2002) Trauma and Substance Abuse: Causes, Consequences, and Treatment of Comorbid Disorders. Washington, DC: American Psychological Association Press. Videos a) Najavits, L.M. (2006). Video training series on Seeking Safety; www.seekingsafety.org (section Order). b) Najavits, L.M., Abueg F, Brown PJ, et al. (1998). Nevada City, CA: Cavalcade [800-345-5530]. Trauma and substance abuse. Part I: Therapeutic approaches [For professionals]; Part II: Special treatment issues [For professionals]; Numbing the Pain: Substance abuse and psychological trauma [For clients] Clinically-Relevant Articles 1. Seal, KH, Bertenthal, D, Miner, CR, Sen, S, Marmar, C (2007). Bringing the war back home: mental health disorders among 103 788 us veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476-482. 2. Golier, J.A., Yehuda, R. et al. (2003). The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events. American J Psychiatry,160, 2018-24. 3. Najavits, LM, Schmitz, M, Johnson, KM, Smith, C, North, T et al. (2009). Seeking Safety therapy for men: Clinical and research experiences. In Men and Addictions. Nova Science Publishers, Hauppauge, NY. 4. Brady, K.T., Dansky, B.S. et al. (2001). Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: Preliminary findings. J Substance Abuse Treatment, 21, 47-54. 5. Bradley, R., Greene J., et al. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214-227. 6. Kessler, R.C., Sonnega, A., et al. (1995). Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry, 52, 1048-1060. [Provides rates] 7. Najavits, L.M. (2004). Assessment of trauma, PTSD, and substance use disorder: A practical guide. In J. P. Wilson & T. M. Keane (Eds.), Assessment of Psychological Trauma and PTSD (pp. 466-491). New York: Guilford. 8. Ougrin D. (2011). Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta-analysis. BMC Psychiatry. 11(1):200. 9. Vogelmann-Sine, S., Sine, L., et al. (1998). EMDR: Chemical Dependency Treatment Manual. Unpublished manuscript, Honolulu, Hawaii. 10. Najavits, L., Highley, J., Dolan, S., & Fee, F. (2012). Substance use disorder, PTSD, and traumatic brain injury. In J. Vasterling, R. Bryant & T. Keane (Eds.), PTSD and Mild Traumatic Brain Injury. New York: Guilford Press 11. Najavits LM (2007). Psychosocial treatments for posttraumatic stress disorder. In P. E. Nathan & J. Gorman, A Guide to Treatments that Work (3rd ed.). Oxford Press: New York. 12. Brown et al. (2007). Implementing an evidence-based practice: Seeking Safety group. Journal of Psychoactive Drugs, 39, 231-240. Pubmed (medical literature): http://www.ncbi.nlm.nih.gov/entrez/

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With appreciation to the Allies Program (Sacramento, CA) for formatting this Safe Coping List.

Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002). Only for personal use (with clients); for any other use contact or

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Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002). Only for personal use (with clients); for any other use contact or

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Lisa Najavits, PhD

Detaching From Emotional Pain (Grounding)

WHAT IS GROUNDING?

Grounding is a set of simple strategies to detach from emotional pain (for example, drug cravings, self-harm impulses, anger, sadness). Distraction works by focusing outward on the external world-- rather than inward toward the self. You can also think of it as distraction, centering, a safe place, looking outward, or healthy detachment.

WHY DO GROUNDING?

When you are overwhelmed with emotional pain, you need a way to detach so that you can gain control over your feelings and stay safe. As long as you are grounding, you cannot possibly use substances or hurt yourself! Grounding anchors you to the present and to reality. Many people with PTSD and substance abuse struggle with either feeling too much (overwhelming emotions and memories) or too little (numbing and dissociation). In grounding, you attain balance between the two-- conscious of reality and able to tolerate it.

Guidelines Grounding can be done any time, any place, anywhere and no one has to know. Use grounding when you are: faced with a trigger, having a flashback, dissociating, having a substance craving, or when your emotional pain goes above 6 (on a 0-10 scale). Grounding puts healthy distance between you and these negative feelings. Keep your eyes open, scan the room, and turn the light on to stay in touch with the present. Rate your mood before and after to test whether it worked. Before grounding, rate your level of emotional pain (0-10, where means extreme pain). Then re-rate it afterwards. Has it gone down? No talking about negative feelings or journal writing. You want to distract away from negative feelings, not get in touch with them. Stay neutral-- no judgments of good and bad. For example, The walls are blue; I dislike blue because it reminds me of depression. Simply say The walls are blue and move on. Focus on the present, not the past or future. Note that grounding is not the same as relaxation training. Grounding is much more active, focuses on distraction strategies, and is intended to help extreme negative feelings. It is believed to be more effective for PTSD than relaxation training. WAYS TO GROUND

Mental Grounding Describe your environment in detail using all your senses. For example, The walls are white, there are five pink chairs, there is a wooden bookshelf against the wall... Describe objects, sounds, textures, colors, smells, shapes, numbers, and temperature. You can do this anywhere. For example, on the subway: Im on the subway. Ill see the river soon. Those are the windows. This is the bench. The metal bar is silver. The subway map has four colors... Play a categories game with yourself. Try to think of types of dogs, jazz musicians, states that begin with A, cars, TV shows, writers, sports, songs, European cities. Do an age progression. If you have regressed to a younger age (e.g., 8 years old), you can slowly work your way back up (e.g., Im now 9; Im now 10; Im now 11) until you are back to your current age. Describe an everyday activity in great detail. For example, describe a meal that you cook (e.g., First I peel the potatoes and cut them into quarters, then I boil the water, I make an herb marinade of oregano, basil, garlic, and olive oil). Imagine. Use an image: Glide along on skates away from your pain; change the TV channel to get to a better show; think of a wall as a buffer between you and your pain. Say a safety statement. My name is ____; I am safe right now. I am in the present, not the past. I am located in _____; the date is _____. Read something, saying each word to yourself. Or read each letter backwards so that you focus on the letters and not on the meaning of words. Use humor. Think of something funny to jolt yourself out of your mood. Count to 10 or say the alphabet, very s..l..o..w..l..y. Repeat a favorite saying to yourself over and over (e.g., the Serenity Prayer).

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Physical Grounding

Run cool or warm water over your hands. Grab tightly onto your chair as hard as you can. Touch various objects around you: a pen, keys, your clothing, the table, the walls. Notice textures, colors,

materials, weight, temperature. Compare objects you touch: Is one colder? Lighter? Dig your heels into the floor-- literally grounding them! Notice the tension centered in your heels as you

do this. Remind yourself that you are connected to the ground. Carry a grounding object in your pocket-- a small object (a small rock, clay, ring, piece of cloth or yarn) that

you can touch whenever you feel triggered. Jump up and down. Notice your body: The weight of your body in the chair; wiggling your toes in your socks; the feel of your

back against the chair. You are connected to the world. Stretch. Extend your fingers, arms or legs as far as you can; roll your head around. Walk slowly, noticing each footstep, saying left,right with each step. Eat something, describing the flavors in detail to yourself. Focus on your breathing, noticing each inhale and exhale. Repeat a pleasant word to yourself on each

inhale (for example, a favorite color or a soothing word such as safe, or easy). Soothing Grounding

Say kind statements, as if you were talking to a small child. E.g., You are a good person going through a hard time. Youll get through this.

Think of favorites. Think of your favorite color, animal, season, food, time of day, TV show. Picture people you care about (e.g., your children; and look at photographs of them). Remember the words to an inspiring song, quotation, or poem that makes you feel better (e.g., the Serenity

Prayer). Remember a safe place. Describe a place that you find very soothing (perhaps the beach or mountains, or

a favorite room); focus on everything about that place-- the sounds, colors, shapes, objects, textures. Say a coping statement. I can handle this, This feeling will pass. Plan out a safe treat for yourself, such as a piece of candy, a nice dinner, or a warm bath. Think of things you are looking forward to in the next week, perhaps time with a friend or going to a movie. WHAT IF GROUNDING DOES NOT WORK?

Practice as often as possible, even when you dont need it, so that youll know it by heart. Practice faster. Speeding up the pace gets you focused on the outside world quickly. Try grounding for a looooooonnnnngggg time (20-30 minutes). And, repeat, repeat, repeat. Try to notice whether you do better with physical or mental grounding. Create your own methods of grounding. Any method you make up may be worth much more than those

you read here because it is yours.

Start grounding early in a negative mood cycle. Start when the substance craving just starts or when you have just started having a flashback.

Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002). Only for personal use (with clients); for any other use contact or

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Lisa Najavits, PhD

Taking Good Care of Yourself

Answer each question below yes or no.; if a question does not apply, leave it blank.

DO YOU

Associate only with safe people who do not abuse or hurt you? YES___ NO___

Have annual medical check-ups with a:

Doctor? YES___ NO ___ Dentist? YES___ NO ___

Eye doctor? YES ___NO ___ Gynecologist (women only)? YES ___ NO ___

Eat a healthful diet? (healthful foods and not under- or over-eating) YES ___ NO ___

Have safe sex? YES ___ NO ___

Travel in safe areas, avoiding risky situations (e.g., being alone in deserted areas)? YES ___ NO ___

Get enough sleep? YES ___ NO ___

Keep up with daily hygiene (clean clothes, showers, brushing teeth, etc.)? YES ___ NO ___

Get adequate exercise (not too much nor too little)? YES ___ NO ___

Take all medications as prescribed? YES __ NO___

Maintain your car so it is not in danger of breaking down? YES ___ NO ___

Avoid walking or jogging alone at night? YES___ NO ___

Spend within your financial means? YES___ NO ___

Pay your bills on time? YES___ NO ___

Know who to call if you are facing domestic violence? YES___ NO ___

Have safe housing? YES___ NO ___

Always drive substance-free? YES___ NO ___

Drive safely (within 5 miles of the speed limit)? YES___NO___

Refrain from bringing strangers home to your place? YES___ NO ___

Carry cash, ID, and a health insurance card in case of danger? YES___ NO ___

Currently have at least two drug-free friendships? YES ___ NO ___

Have health insurance? YES___ NO ___

Go to the doctor/dentist for problems that need medical attention? YES__NO__

Avoid hiking or biking alone in deserted areas? YES___ NO ___

Use drugs or alcohol in moderation or not at all? YES ___ NO ___

Not smoke cigarettes? YES ___ NO ___

Limit caffeine to fewer than 4 cups of coffee per day or 7 colas? YES ___ NO ___

Have at least one hour of free time to yourself per day? YES ___ NO ___

Do something pleasurable every day (e.g., go for a walk)? YES___ NO___

Have at least three recreational activities that you enjoy (e.g., sports, hobbies but not substance use!) ?

YES___ NO___

Take vitamins daily? YES___NO___

Have at least one person in your life that you can truly talk to (therapist, friend, sponsor, spouse)? YES___NO___

Use contraceptives as needed? YES___NO___

Have at least one social contact every week? YES___NO___

Attend treatment regularly (e.g., therapy, group, self-help groups)? YES___NO___

Have at least 10 hours per week of structured time? YES ___ NO ___

Have a daily schedule and to do list to help you stay organized? YES___NO___

Attend religious services (if you like them)? YES___ NO___ N/A___

Other: ______________________________ YES ___ NO ___

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YOUR SCORE: (total # of nos) ______

Notes on self-care: Self-Care and PTSD. People with PTSD often need to learn to take good care of themselves. For example, if

you think about suicide a lot, you may not feel that its worthwhile to take good care of yourself and may need

to make special efforts to do so. If you were abused as a child you got the message that your needs were not

important. You may think, If no one else cares about me, why should I? Now is the time to start treating

yourself with respect and dignity.

Self-Care and Substance Abuse. Excessive substance use is one of the most extreme forms of self-neglect

because it directly harms your body. And, the more you abuse substances the more you are likely to neglect

yourself in other ways too (e.g., poor diet, lack of sleep).

Try to do a little more self-care each day. No one is perfect in doing everything on the list at all times.

However, the goal is to take care of the most urgent priorities first and to work on improving your self-care

through daily efforts. Progress, not perfection.

Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002). Only for personal use (with clients); for any other use contact or

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Najavits, LM (2002)

Creating Meaning in PTSD and Substance Abuse MEANINGS THAT

HARM

DEFINITION EXAMPLES MEANINGS THAT

HEAL

Deprivation

Reasoning

Because you have

suffered a lot, you deserve

substances (or other

destructive behavior).

--Ive had a hard time, so

Im entitled to get high.

--If you went through what I

did, youd cut your arm too.

Live Well. A happy,

functional life will make

up for your suffering far

more than will hurting

yourself. Focus on

positive steps to make

your life better.

Im Crazy

You believe that you

shouldnt feel the way

you do

--I must be crazy to be

feeling this upset.

--I shouldnt have this

craving.

Honor Your Feelings.

You are not crazy. Your

feelings make sense in

light of what you have

been through. You can

get over them by talking

about them and learning

to cope.

Time Warp It feels like a negative

feeling will go on forever.

--This craving wont stop.

--If I were to cry, I would

never stop.

Observe Real Time.

Take a clock and time

how long it really lasts.

Negative feelings will

usually subside after a

while; often they will go

away sooner if you

distract with activities.

Actions Speak

Louder than Words

Show distress by actions,

or people wont see the

pain.

--Scratches on my arml

show what I feel

--An overdose will show

them.

Break Through the

Silence. Put feelings

into words. Language is

the most powerful

communication for

people to know you.

Beating Yourself

Up

In your mind, you yell at

yourself and put yourself

down.

--Im a loser.

--Im a no-good piece of

dirt.

LoveNot Hate--

Creates Change.

Beating yourself up does

not change your

behavior. Care and

understanding promote

real change.

The Past is the

Present

Because you were a

victim in the past, you are

a victim in the present.

--I cant trust anyone.

--Im trapped. Notice Your Power. Stay in the present: I am

an adult (no longer a

child); I have choices (I

am not trapped); I am

getting help (I am not

alone).

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The Escape An escape is needed (e.g.,

food, cutting) because

feelings are too painful

--Ill never get over this; I

have to cut myself.

--I cant stand cravings; I

have to smoke a joint.

Keep Growing. Emotional growth and

learning are the only real

escape from pain. You

can learn to tolerate

feelings and solve

problems.

Ignoring Cues If you dont notice a

problem it will go away.

--If I just ignore this

toothache it will go away

--I dont abuse substances.

Attend to Your Needs. Listen to what youre

hearing; notice what

youre seeing; believe

your gut feeling.

Dangerous

Permission

You give yourself

permission for self-

destructive behavior.

--Just one wont hurt.

--Ill just buy a bottle of

wine for a new recipe

Seek Safety.

Acknowledge your urges

and feelings and then

find a safe way to cope

with them.

The Squeaky Wheel

Gets the Grease

If you get better you will

not get as much attention

from people

--If I do well, my therapist

wont notice me.

--No one will listen to me

unless Im in distress.

Get Attention from

Success. People love to

pay attention to success.

If you dont believe this,

try doing better and

notice how people

respond to you.

Its All My Fault Everything that goes

wrong is due to you.

--The trauma was my fault

--If I have a disagreement

with someone, it means Im

wrong.

Give Yourself a Break.

Dont carry the world on

your shoulders. When

you have conflicts with

others, try taking a 50-50

approach (50% is their

responsibility, 50% is

yours).

I am My Trauma Your trauma is your

identity; it is more

important than anything

else

--My life is pain.

--I am what I have

suffered..

Create a Broad

Identity. You are more

than what you have

suffered. Think of your

different roles in life,

your varied interests,

your goals and hopes.

Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002). Only for personal use (with clients); for any other use contact or

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PTSD Checklist-Civilian Version

INSTRUCTIONS:

1) List here the trauma (stressful event) that is being rated: _____________________________________________________.

[Clinician: be sure to check that the trauma listed fits criterion A see DSM-IV or DSM-IV-TR]

2) Below is a list of problems and complaints that people sometimes have in response to stressful experiences. Please read each one

carefully, and check off the box to indicate how much you have been bothered by that problem in the past month, in relation to the

trauma you listed in 1 above.

Not at all

A little

bit

Moderately Quite a

bit

Extremely

1. Repeated, disturbing memories, thoughts, or

images of a stressful experience?

1 2 3 4 5

2. Repeated, disturbing dreams of a stressful

experience?

1 2 3 4 5

3. Suddenly acting or feeling as if a stressful

experience were happening again (as if you

were reliving it)?

1 2 3 4 5

4. Feeling very upset when something

reminded you of a stressful experience?

1 2 3 4 5

5. Having physical reactions (e.g., heart

pounding, trouble breathing, sweating)

when something reminded you of a stressful

experience?

1 2 3 4 5

6. Avoiding thinking about or talking about a

stressful experience or avoiding having

feelings related to it?

1 2 3 4 5

7. Avoiding activities or situations because

they reminded you of a stressful experience?

1 2 3 4 5

8. Trouble remembering important parts of a

stressful experience?

1 2 3 4 5

9. Loss of interest in activities that you used to

enjoy?

1 2 3 4 5

10. Feeling distant or cut off from other people? 1 2 3 4 5

14

11. Feeling emotionally numb or being unable

to have loving feelings for those close to

you?

1 2 3 4 5

12. Feeling as if your future will somehow be

cut short?

1 2 3 4 5

13. Trouble falling or staying asleep? 1 2 3 4 5

14. Feeling irritable or having angry outbursts? 1 2 3 4 5

15. Having difficulty concentrating? 1 2 3 4 5

16. Being "super-alert" or watchful or on

guard?

1 2 3 4 5

17. Feeling jumpy or easily startled? 1 2 3 4 5

PCL-M for DSM-IV (11/1/94) END OF TEST

Citation: Weathers, Litz, Huska, & Keane; National Center for PTSD - Behavioral Science Division; This is a

government document in the public domain.

The instructions have been adapted by Lisa Najavits to include the listing of the trauma, and to include the

scoring below. For other information on the measure, go to www.ncptsd.org.

Before administering, remove scoring below!

-----------------------------------------------Scoring for PCL-C---------------------------------------------------------------

Scoring: any item endorsed at 3 or higher counts as a symptom. PTSD Criterion B: 1 or more from items 1-5;

criterion C: 3 or more from items 6-12; criterion D: 2 or more from items 13-17.

--------------------------------------------Scoring for Trauma Symptom Checklist-40 (next page)-----------------------

****Before scoring, read important note at bottom of next page****

Subscale composition and scoring for the TSC-40 The score for each subscale is the sum of the relevant items:

Dissociation: 7,14,16,25,31,38

Anxiety: 1,4,10,16,21,27,32,34,39

Depression: 2,3,9,15,19,20,26,33,37

SATI (Sexual Abuse Trauma Index): 5,7,13,21,25,29,31

Sleep Disturbance 2,8,13,19,22,28

Sexual Problems 5,9,11,17,23,29,35,40

TSC-40 total score: 1-40

Najavits, Lisa M. (2006). Training on PTSD and Substance Abuse, and Seeking Safety.

15

Trauma Symptom Checklist-40

How often have you experienced each of the following in the last month? Please circle one number, 0 through 3.

Never Often 1. Headaches 0 1 2 3__ 2. Insomnia 0 1 2 3__ 3. Weight loss (without dieting) 0 1 2 3__ 4. Stomach problems 0 1 2 3__ 5. Sexual problems 0 1 2 3__ 6. Feeling isolated from others 0 1 2 3__ 7. "Flashbacks"(sudden, vivid, distracting memories) 0 1 2 3__ 8. Restless sleep 0 1 2 3__ 9. Low sex drive 0 1 2 3__ 10. Anxiety attacks 0 1 2 3__ 11. Sexual overactivity 0 1 2 3__ 12. Loneliness 0 1 2 3__ 13. Nightmares 0 1 2 3__ 14. "Spacing out" (going away in your mind) 0 1 2 3__ 15. Sadness 0 1 2 3__ 16. Dizziness 0 1 2 3__ 17. Not feeling satisfied with your sex life 0 1 2 3__ 18. Trouble controlling your temper 0 1 2 3__ 19. Waking up early in the morning 0 1 2 3__ 20. Uncontrollable crying 0 1 2 3__ 21. Fear of men 0 1 2 3__ 22. Not feeling rested in the morning 0 1 2 3__ 23. Having sex that you didn't enjoy 0 1 2 3__ 24. Trouble getting along with others 0 1 2 3__ 25. Memory problems 0 1 2 3__ 26. Desire to physically hurt yourself 0 1 2 3__ 27. Fear of women 0 1 2 3__ 28. Waking up in the middle of the night 0 1 2 3__ 29. Bad thoughts or feelings during sex 0 1 2 3__ 30. Passing out 0 1 2 3__ 31. Feeling that things are "unreal" 0 1 2 3__ 32. Unnecessary or over-frequent washing 0 1 2 3__ 33. Feelings of inferiority 0 1 2 3__ 34. Feeling tense all the time 0 1 2 3__ 35. Being confused about your sexual feelings 0 1 2 3 36. Desire to physically hurt others 0 1 2 3__ 37. Feelings of guilt 0 1 2 3__ 38. Feeling that you are not always in your body 0 1 2 3__ 39. Having trouble breathing 0 1 2 3__ 40. Sexual feelings when you shouldn't have them 0 1 2 3__

Important note: this measure assesses trauma-related problems in several categories. According to John Briere, PhD The TSC-40 is a research instrument only. Use of this scale is limited to professional researchers. It is not intended as, nor should it be used as, a self-test under any circumstances. For a more current version of the measure, which can be used for clinical purposes (and for which there is a fee), consider the Trauma Symptom Inventory; contact Psychological Assessment Resources, 800-331-8378. The TSC-40 is freely available to researchers. No additional permission is required for use or reproduction of this measure, although the following citation is needed: Briere, J. N., & Runtz, M. G. (1989). The Trauma Symptom Checklist (TSC-33): Early data on a new scale. Journal of Interpersonal Violence, 4, 151-163. For further information on the measure, go to www.johnbriere.com.

16

ProQOL R-IV PROFESSIONAL QUALITY OF LIFE SCALE

Compassion Satisfaction and Fatigue SubscalesRevision IV

Helping people puts you in direct contact with their lives. As you probably have experienced, your compassion

for those you help has both positive and negative aspects. We would like to ask you questions about your

experiences, both positive and negative, as a helper. Consider each of the following questions about you and

your current situation. Select the number that honestly reflects how frequently you experienced these

characteristics in the last 30 days.

0=Never 1=Rarely 2=A Few Times 3=Somewhat Often 4=Often 5=Very Often

____ 1. I am happy. ____ 2. I am preoccupied with more than one person I help. ____ 3. I get satisfaction from being able to help people. ____ 4. I feel connected to others. ____ 5. I jump or am startled by unexpected sounds. ____ 6. I feel invigorated after working with those I help. ____ 7. I find it difficult to separate my personal life from my life as a helper. ____ 8. I am losing sleep over traumatic experiences of a person I help. ____ 9. I think that I might have been infected by the traumatic stress of those I help. ____ 10. I feel trapped by my work as a helper. ____ 11. Because of my helping, I have felt on edge about various things. ____ 12. I like my work as a helper. ____ 13. I feel depressed as a result of my work as a helper. ____ 14. I feel as though I am experiencing the trauma of someone I have helped . ____ 15. I have beliefs that sustain me. ____ 16. I am pleased with how I am able to keep up with helping techniques and protocols. ____ 17. I am the person I always wanted to be. ____ 18. My work makes me feel satisfied. ____ 19. Because of my work as a helper, I feel exhausted. ____ 20. I have happy thoughts and feelings about those I help and how I could help them. ____ 21. I feel overwhelmed by the amount of work or the size of my casework load I have to

deal with. ____ 22. I believe I can make a difference through my work. ____ 23. I avoid certain activities or situations because they remind me of frightening

experiences of the people I help. ____ 24. I am proud of what I can do to help. ____ 25. As a result of my helping , I have intrusive, frightening thoughts. ____ 26. I feel bogged down by the system. ____ 27. I have thoughts that I am a success as a helper. ____ 28. I can't recall important parts of my work with trauma victims. ____ 29. I am a very sensitive person. ____ 30. I am happy that I chose to do this work.

Copyright Information

B. Hudnall Stamm, 1997-2005. Professional Quality of Life: Compassion Satisfaction and Fatigue Subscales, R-IV (ProQOL). http://www.isu.edu/~bhstamm. This test may be freely copied as long as (a) author is credited, (b) no changes are made other than those authorized below, and (c) it is not sold. You may substitute the appropriate target group for helper if that is not the best term. For example, if you are working with teachers, replace helper with teacher.

17

Disclaimer

This information is presented for educational purposes only. It is not a substitute for informed medical advice or training. Do not use this information to diagnose or treat a health problem without consulting a qualified health or mental health care provider. If you have concerns, contact your health care provider, mental health professional, or your community health center.

Self-scoring directions, if used as self-test

1. Be certain you respond to all items.

2. On some items the scores need to be reversed. Next to your response write the reverse of that score (i.e. 0=0, 1=5,

2=4, 3=3). Reverse the scores on these 5 items: 1, 4, 15, 17 and 29. Please note that the value 0 is not reversed, as

its value is always null.

3. Mark the items for scoring:

a. Put an X by the 10 items that form the Compassion Satisfaction Scale: 3, 6, 12, 16, 18, 20, 22, 24, 27,

30.

b. Put a check by the 10 items on the Burnout Scale: 1, 4, 8, 10, 15, 17, 19, 21, 26, 29.

c. Circle the 10 items on the Trauma/Compassion Fatigue Scale: 2, 5, 7, 9, 11, 13, 14, 23, 25, 28.

4. Add the numbers you wrote next to the items for each set of items and compare with the average scores below.

Compassion Satisfaction Scale. The average score is 37 (SD 7; alpha scale reliability .87). About 25% of people score higher than 42 and about 25% of people score below 33. If you are in the higher range, you probably derive a good deal of

professional satisfaction from your position. If your scores are below 33, you may either find problems with your job, or

there may be some other reasonfor example, you might derive your satisfaction from activities other than your job.

Burnout Scale. The average score on the burnout scale is 22 (SD 6.0; alpha scale reliability .72). About 25% of people score above 27 and about 25% of people score below 18. If your score is below 18, this probably reflects positive feelings about

your ability to be effective in your work. If you score above 27 you may wish to think about what at work makes you feel like

you are not effective in your position. Your score may reflect your mood; perhaps you were having a bad day or are in need

of some time off. If the high score persists or if it is reflective of other worries, it may be a cause for concern.

Trauma/Compassion Fatigue Scale. The average score on this scale is 13 (SD 6; alpha scale reliability .80). About 25% of people score below 8 and about 25% of people score above 17. If your score is above 17, you may want to take some time to

think about what at work may be frightening to you or if there is some other reason for the elevated score. While higher

scores do not mean that you do have a problem, they are an indication that you may want to examine how you feel about your

work and your work environment. You may wish to discuss this with your supervisor, a colleague, or a health care

professional. If you have any concerns, you should discuss them with a health care professional.

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20

Tough Cases -- Rehearsing Difficult Client Scenarios

Below are examples of tough cases in the treatment of PTSD and substance abuse. They are organized by themes related to this dual diagnosis. Trauma/PTSD: Ill never recover from PTSD. Reading about trauma makes me want to burn myself. How can I give up substances when I still have such severe PTSD? Substance Abuse: Using cocaine makes my PTSD betterI cant give it up. Its my alter who drinks and shes not here now (dissociative identity disordered client) I definitely think I can do controlled drinking. Do I have to get clean before working on my PTSD? In AA they said to me, You dont drink because you were molested as a child, you drink because youre

an alcoholic. Self-Nurturing: I just cant experience pleasurenothing feels fun to me. All of the people I know drink to have a good time. Whenever I try to do something pleasurable I feel guilty. My partner doesnt want me to go out of the house. Safety:

I dont want to stay safe; I want to die. Safe coping skills are a nice idea, but when I get triggered its so fast that I dont even have time to think

about what Im doing. I feel like I need mourn my trauma now, not wait until later. Boundaries in Relationships: I cant say no. It makes me feel Im being mean, like my abuser. When I say no to my partner I get hit. I want to set a boundary with you-- stop telling me to get off substances! Im not ready. You tell me to reach out to others, but I feel safer alone. My cousin keeps offering me crack no matter how much I say not to. Honesty: But it will hurt the other person if Im honest. I can be honest in the role-play, but in real life I could never do it. I wont tell my doctor that I abuse alcohol. Should I tell everyone at work that Im an addict? Are you telling me Im a liar? When I was growing up, I told my mother that my brother molested me and she said I was lying. Creating Meaning: My thoughts are bad, just like Im bad. But my negative thoughts really are true! Positive thinking never works for me. Guilford Press, New York. From: Najavits, L.M. Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002). Only for personal use (with clients); for any other use contact or

B. Hudnall Stamm Traumatic Stress Research Group, 1996, 1997 http://www.isu.edu/~bhstamm/index.htm Thisform may be freely copied as long as (a) authors are credited, (b) no changes are made, & (c) it is not sold.

Stressful Life Experiences Screening

Please fill in the number that best represents how much the following statements describe yourexperiences. You will need to use two scales, one for how well the statement describes your experiencesand one for how stressful you found this experience. The two scales are below.

Describes your Experience:0 1 2 3 4 5 6 7 8 9 10

Did notexperiencethis

a little like myexperiences

somewhat likemy experiences

exactly like myexperiences

Stressfulness of Experience:0 1 2 3 4 5 6 7 8 9 10

Not at allstressful

not verystressful

somewhat stressful

extremelystressful

Describesyour

Experience

Life Experience StressfulnessThen

StressfulnessNow

I have witnessed or experienced a natural disaster; like ahurricane or earthquake.I have witnessed or experienced a human made disaster like aplane crash or industrial disaster.I have witnessed or experienced a serious accident or injury.I have witnessed or experienced chemical or radiation exposurehappening to me, a close friend or a family member.I have witnessed or experienced a life threatening illnesshappening to me, a close friend or a family member.I have witnessed or experienced the death of my spouse orchild.I have witnessed or experienced the death of a close friend orfamily member (other than my spouse or child).I or a close friend or family member has been kidnapped ortaken hostage.I or a close friend or family member has been the victim of aterrorist attack or torture.I have been involved in combat or a war or lived in a waraffected area.I have seen or handled dead bodies other than at a funeral.I have felt responsible for the serious injury or death of anotherperson.I have witnessed or been attacked with a weapon other than incombat or family settingAs a child/teen I was hit, spanked, choked or pushed hardenough to cause injuryAs an adult, I was hit, choked or pushed hard enough to causeinjuryAs an adult or child, I have witnessed someone else beingchoked, hit, spanked, or pushed hard enough to cause injury.As a child/teen I was forced to have unwanted sexual contact.As an adult I was forced to have unwanted sexual contact.As a child or adult I have witnessed someone else being forcedto have unwanted sexual contactI have witnessed or experienced an extremely stressful event notalready mentioned. Please Explain: